This resource was developed in collaboration with health care professionals and educators to provide critical information
and resources for school personnel working with children who have, or who are suspected as having, ADHD.

Identification of ADHD

OverviewAttention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder that affects all aspects of a child’s
life, including school, home, social relations, and extra-curricular activities. A child can be diagnosed with ADHD with
hyperactive subtype, inattentive subtype, or combined-type (both hyperactive and inattentive). What many people refer to
as attention-deficit disorder (ADD) is actually just the inattentive subtype of ADHD; ADD is an outdated term and was formally changed to ADHD in 1994.

PrevalenceADHD is one of the most common chronic disorders of childhood. In a classroom of 30 children, it would not be unreasonable
to expect 3 kids to have ADHD. [U.S.: 2014] Boys are more than twice as likely as girls to receive this diagnosis. [Visser: 2014] Prevalence of ADHD is rising in the United States; it is unclear if a greater number of children have the condition, or if
there is better recognition of it - or both.

Behavior that School Personnel May See

Christopher Futcher/Istock Photo

Teachers are often the first to see behaviors that may be suggestive of ADHD:

Problems waiting for his or her turn, interrupting other kids, acts without thinking

In addition to the challenging behavior, teachers may see positive traits:

Creativity, brings new ideas to the classroom, artistic talent

Ability to identify what others do not see, has a fresh perspective

Enthusiasm and spontaneity

Mental flexibility, intelligence

Working with Parents and Physicians: Before a Diagnosis School personnel should never say, in any way, “I think your child has ADHD,” or recommend that a child should see a pediatrician.
Instead, when a student is suspected of having ADHD, it is wise to have regular discussions with the family about the child’s
observed strengths and challenging behaviors in the school setting:

Ask parents if there are similar challenges at home or in other settings, but do not assume that the child acts the same way
outside of school.

Share with the family any testing and interventions that the school team has already implemented to support the child, and
the child’s response to those interventions. Encourage families to share your documentation with the child’s primary healthcare
provider.

It can be helpful to explain that you are concerned that ADHD or another untreated medical condition may be keeping the child
from achieving his or her full potential, but it is not appropriate for a teacher to tell a parent that their child has ADHD.
(This is making a diagnosis.)

If it is difficult finding the right words to communicate your concerns with families, consider statements such as:
“We/I’ve noticed that Johnny sometimes demonstrates __________(the following behaviors) in class. Have you had similar concerns
at home? Have you ever talked about these behaviors/concerns with your pediatrician?”

It can take time for a family to agree that their child should get a medical evaluation, and
it is the parents' choice on whether to follow up with medical help or not. In the meantime, school staff should work as a
team to support the child, the other students, and the teachers who interact with the child.

Diagnosis of ADHD

The child’s medical home clinician often is the person who makes the diagnosis of ADHD; however, supporting information from
the parents and educators plays an integral role.
School staff should provide the family with relevant behavioral observations, test results, and supporting documentation.
Specific screening forms, such as the NICHQ Vanderbilt Parent & Teacher Initial and Follow-Up Assessments with Scoring Instructions ( 1.1 MB), can be shared with the family, who then may discuss the ratings with their child’s clinician. Talking directly with the
clinician can be helpful, too; if there is a mental health specialist familiar with the child, this person should also be
consulted. Discussing a student with subspecialists external to the educational system requires written consent from the parent
on school forms. See Communicating with the Medical Provider, below.

Barriers to Diagnosis and Treatment

It can take time to make a diagnosis of ADHD because the diagnosis requires impaired function in 2 or more of the child’s
regular settings (home and school being the most common).

Teachers may have multiple students with ADHD or other behavioral, developmental, medical, or learning problems.

Recognition of students with the inattentive subtype can be relatively slow because these students may present with quiet
school failure or not achieving their potential, but are not necessarily disruptive to others.

Parents often lack the perspective to know that their child has a medical problem, and can feel embarrassed or angry that
their child is struggling in school.

Parents may perceive a poor fit between the student and teacher, and may wait to see if the issues resolve with next year’s
teacher.

Children with ADHD and high cognitive function may not struggle with academics until the material becomes increasingly complex.

The school may have limited access to a psychologist who can help in this process.

The child may not have a primary care provider (a medical home) or may lack insurance to cover medical visits or medications.

Parents also may have symptoms of ADHD, and this can make it difficult for them to follow through on medical and school appointments.

Many people worry about using medications to treat ADHD in children.

Minorities and uninsured children are less likely to get a diagnosis (and therefore treatment) of ADHD.

Working with Parents and Clinicians: After a Diagnosis

When children are trialing medications, frequent feedback helps ensure appropriate therapy; let the family know about improvements
or side effects that you may observe.

When a child divides time between different households, taking medication regularly can be challenging; families can arrange
for medication to be given at school if needed.

Continue working on behavioral and academic supports in the school setting. Medication can be very helpful in managing symptoms,
but it does not cure ADHD. Teach children how to structure and organize their learning environment so that they can learn
to manage ADHD on their own, with or without medications.

Interventions in the School Setting

Visual schedules. Post them and stick to them. If children have difficulty following the class schedule, they can have their own visual schedule
at their desk.

ABC’s of behavior (antecedents, behaviors, and consequences). Be aware of what the child is getting out of the maladaptive behavior. Is there
a better way to meet this need? Documenting can help in recognizing behavior patterns and in developing individualized interventions.
The ABCs of Behavior provides more details.

Response to Intervention (RTI). Use it to develop meaningful interventions and to determine the need for additional behavioral supports. See RTI Action Network (NCLD).

Brain breaks. Use of short breaks throughout the day for children to move around and have fun improves attention spans. See Brain Breaks (Go Noodle).

Exercise. Encourage kids with ADHD to get exercise before school (e.g., walking or riding a bike to school) and to be active during
recess. Exercise increases blood flow to the brain and helps kids improve their academic performance. It is counter-productive to penalize children with ADHD by taking away recess time.

Nutrition. Ensure that the child with ADHD is getting a nutritious breakfast and lunch. Stimulant medications may suppress appetite,
and a noisy lunchroom can also be very distracting. Consider recess before lunch, instead of after lunch, so that children
are not skipping lunch to play. Avoid caffeine and sports drinks.

Support. Be supportive and patient. Children with ADHD are not there to make your life worse. Many children with ADHD feel bad
about being considered disruptive, lazy, or stupid. Messages they get from educators and school staff can help them understand
that they are not bad kids. Be sure to reinforce positive behaviors and notice small steps in the right direction.

Be an ally. Kids with ADHD may appreciate special passwords or signals to indicate that they need to get up and move around. Consider
asking these kids to pass out papers, sharpen pencils, take things to the office, etc. Children who take medications at school
may feel embarrassed if other students know that they are leaving class to take their medicine, so develop a strategy to help
protect the student’s privacy.

Team approach. Document responses to interventions and share successful (and unsuccessful) strategies with other school staff who work
with the same child.

Psychologists can perform testing to understand if the child has learning disabilities or autism spectrum disorders that affect
the educational setting. They may also help with evaluating the child and accessing resources such as anger management or
social skills groups.

Occupational therapists often have tools that can help children with ADHD, such as wiggly seats or balls to sit on, time-on-task
buzzers/reminders, headphones, etc.

Special educators can assist in behavioral observation and interventions.

Nurses can provide additional information about the child’s medical condition and possible side effects of medications.

Physical therapists are good resources for children with both coordination disorder and ADHD.

Speech therapists are helpful when there is a concurrent language disorder.

Administrators can help with coordinating a school-wide (or district-wide) behavioral plan to ensure consistency in all the
child’s school settings.

Other teachers and aides may have insights and experiences to share as well, and can be an excellent source of support.

Parents can be great resources for how best to work with their child, and what to do when things are not going well. If you
have useful strategies that work at school for a child, share these with interested parents to promote consistency across
settings.

Information about ADHD Treatments

Medication and behavioral supports are the main evidence-based treatments of ADHD.

Stimulant MedicationsStimulants can decrease symptoms of ADHD, including hyperactivity, impulsivity, inattentiveness, and trouble getting along
with others. Stimulants are recommended as first-line treatment for children 6 years old and older by the American Academy
of Pediatrics and the American Academy of Child and Adolescent Psychiatry. [Wolraich: 2011][Pliszka: 2007] Stimulant medications work on certain neuroreceptors in the brain. Approximately 75% of children with ADHD will respond to
stimulant treatment if dosing is correct. Stimulant medications fall into two classes: (1) methylphenidates (includes Ritalin,
Methylin, Metadate, Concerta, Daytrana, Focalin, Quillivant, Aptensio) and (2) amphetamines (includes Adderall, Dexedrine,
ProCentra, Zenzedi, Vyvanse). Both classes have shorter- and longer-acting release formulas to make them effective for 2-12
hours.

Common side effects can include mild bellyaches and headaches, depressed appetite and weight loss, difficulty sleeping, increased
blood pressure and heart rate, irritability, and anxiety. Risks for stimulant misuse include sharing or selling to other students
or having medications stolen.

Non-stimulant MedicationsNon-stimulants can be considered when side effects, lack of effect, or other concerns interfere with the use of stimulant
medications. These medications take longer to reach full effect, so it can take a while to see if they work.

Some antidepressants can be used to help with ADHD; however, little data for use in children exists, and they can have significant
side effects.

Natural TreatmentsMind-Body Approaches to help with attention and self-regulation

Yoga

Exercise (such as martial arts)

EEG neurofeedback (Although there is some support for use of neurofeedback for ADHD, this therapy is often not covered by
insurance and has significant out of pocket expenses for the family. Effects are not maintained once treatment has been discontinued.)

Dietary Approaches

Omegas. Although treatment with stimulants was shown as more effective, some evidence supports use of high dose Omega 3 and 6 fatty
acids for treatment of ADHD.

Diet. A healthy diet with whole grains, fruits, vegetables, and lean protein sources, and maintaining even blood sugar and insulin
levels by eating frequent, smaller meals, are reasonable approaches to aiding in the management of ADHD. Not a lot of evidence
supports a particular diet; however, analysis of the 2011 Impact of Nutrition on Children with ADHD (INCA) study suggests
that a medically supervised food elimination trial may be an approach to consider. [Pelsser: 2011] In contrast, European guidelines indicate no evidence for elimination diets unless there are GI symptoms. There is lack of
evidence for exclusively organic diets to help ADHD symptoms.

Food dyes. There is some evidence for avoiding food dyes to reduce some ADHD symptoms in some children.

Other ApproachesPopular alternative practices for managing ADHD symptoms also include herbal supplements, homeopathic treatments, vision therapy,
chiropractic adjustments, yeast infection treatments, anti–motion-sickness medication, metronome training, auditory stimulation,
and applied kinesiology (realigning bones in the skull). Many of these approaches are not proven effective, or are detrimental to the child's health.

Overdiagnosis or Misdiagnosis

Many people worry that normal childhood “disruptive” behaviors are misdiagnosed as ADHD, particularly among active little
boys. While making the diagnosis can facilitate helpful interventions, labelling and medicating active children without ADHD
can be harmful. This is why the diagnosis should be made cautiously and with input from people who are familiar with the child
in different settings.

Look-alike conditionsSeveral other conditions can result in inattentive or hyperactive symptoms that may be mistaken for ADHD, but do not respond
to traditional ADHD treatments:

• Substance abuse

• Sleep problems

• Hunger or poor nutrition

• Anxiety

• Depression and bipolar disorder

• Autism spectrum disorder

• Traumatic stress through home or community violence, homelessness or displacement, loss or imprisonment of a parent, etc.

• Learning problems caused by other factors (e.g., moving and changing schools often, frequent absences, learning English
as a second language)

Related ConditionsChildren with ADHD can have other conditions, complicating diagnosis and treatment: (Conditions that have a link lead to Portal
diagnosis and management information.)

Communicating with the Medical Provider

Contacting the prescribing clinician can be helpful if you have specific questions or concerns about the child’s medical treatment.
The family’s permission is necessary for you to have direct communication with the medical provider.

To secure permission, written consent is needed from the parent or guardian to authorize transfer of records, verbal and/or
e-mail communications, etc., as appropriate. For more information about privacy rights see the Portal's section about Education & Schools. Sample forms to enhance communication between medical provider and schools can be found at Forms for Education.

Faxes, phone calls, e-mails, and (less frequently) in-person meetings are all methods to communicate with the medical provider;
however, like educators, clinicians are often difficult to reach directly while they are working. If direct communication
is challenging, see if the physician has a care manager who can help facilitate the process. This is typically a person such
as a nurse, medical assistant, or social worker in the clinic who is familiar with more complex patients in the practice,
but is not a prescriber.

Resources

Information & Support

Teaching

Teaching Children with ADHD (DOE)Instructional strategies and practices for academic instruction, behavioral interventions, and classroom accommodations for
children with ADHD; U.S. Department of Education.

Tough Kid Tool Box (2009) and The Tough Kid Book 2nd ed. (2009) by William R. Jenson, Ginger Rhode, H. Kenton Reavis Books with practical classroom management strategies for teachers to deal more effectively with aggression, arguing, tantrums,
and lack of following directions. Tool Box contains ready-to-use reproducible materials for use in the classroom.

Lost at School: Why Our Kids with Behavioral Challenges are Falling through the Cracks and How We Can Help Them (2014) by Ross Greene, PhD Book that helps educators and parents work together to support and manage behaviorally challenging students.

Practical Ideas That Really Work for Students with ADHD (2005) by Kathleen McConnell and Gail Reyser Workbooks with activities that can be used to improve students' attending and organizational skills and to decrease their
problem behaviors stemming from impulsivity and hyperactivity. Three versions cover grades K-12.

How to Reach and Teach Children with ADD/ADHD: Practical Techniques, Strategies, and Interventions Paperback (2005) by Sandra Rief Book for classroom management and interventions, plus case studies, for teachers of students with ADHD.

LD Online (WETA)On-line resources for teaching students with learning disabilities and ADHD. Includes many useful articles as well as a link
to an on-line learning store; WETA, an educational service of public television station in Washington, D.C.

Think through MathA state-based, adaptive math, paid-subscription program for grades 3 and above.

RTI Action Network (NCLD)Discusses how to maximize student learning and the impact of effective interventions by preventing the development, and lessening
the intensity, of problem behaviors; National Center for Learning Disabilities.

Getting More Information (for School Personnel, Families, and Students)

Children and Adults with ADHD (CHADD)A national non-profit organization, with numerous local chapters, that provides education, advocacy, and support for individuals
with ADHD; Children and Adults with Attention Deficit/Hyperactivity Disorder.

Healthy Children (AAP)Offers information and advice about child development, health, and parenting; American Academy of Pediatrics.

Child Development InstituteInformation, products, and services related to child development, psychology, health, parenting, media, entertainment, and
family activities. Helps families to connect with other parents, professionals, and organizations.

The Diet Factor in ADHD (AAP)A comprehensive overview of the role of dietary methods for treatment of children with ADHD when pharmacotherapy has proven
unsatisfactory or unacceptable; American Academy of Pediatrics.

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children (2014) by Ross Greene PhD Book that details a collaborative, empowering, problem-solving approach for parents to use with children who are hard to manage
using traditional parenting approaches.

ADHD: What Every Parent Needs to Know (2011) edited by Michael I. Reiff, MD, FAAP Book published by the American Academy of Pediatrics for families of children with ADHD.

Boys Adrift (2009) by Leonard Sax, MD Book about 5 factors that are driving the growing epidemic of unmotivated boys and underachieving young men.

U.S. Department of Health and Human Services.Key Findings: Trends in the Parent-Report of Health Care Provider-Diagnosis and Medication Treatment for ADHD: United States,
2003—2011.Centers for Disease Control and Prevention; (2014)
http://www.cdc.gov/ncbddd/adhd/features/key-findings-adhd72013.html. Accessed on July 2015.Study findings.